OFFICE USE ONLY. Registration Date _________ Course _____________________ Course # ___________ **This form must be typed** STUDENT INFORMATION Name: (First, Middle I., Last) Major: CWU I.D. Number: Work Phone: Evening Phone: Cell Phone: Mailing Address during Internship: _____ _________ City: State: Country*: Zip: CWU email: SKYPE Address______________ Cumulative Credits: (Must have 45 credits to be eligible for 290; 90 credits for 490; grad student for 590 or 690) Current Cumulative GPA: Class Standing: Fresh Soph Jr Sr Post Bac Grad Quarter to Be Registered: 20 Expected Graduating Qtr/Yr: Are you an International Student with a F1 visa? Yes No International students on a F1 visa must obtain the signature of the International Student Advisor Is your internship abroad? Yes No If so- complete the Education Abroad Application. Please take this completed agreement for signature to Study Abroad & Exchange Programs located in room 101 in the International Center if the experience will take place outside of the United States. Have you signed the Student Cooperative Education/Internship Release Form? Yes No Date Have you completed the Sexual Harassment Training? Yes No Attach Certificate of Completion to this form. xxxx://xxx.xxx.xxx/student-employment/required-student-training Date Have you purchased Liability Insurance through the University? (now required) Yes No Date Insurance for non-medical settings and for medical settings. Attach proof of insurance to this form. PLACEMENT INFORMATION Employing Agency: Web URL: Internship Position Title: Business or Agency Type / Industry: Non-Profit For Profit Government Education Employer Mailing Address: (POB or Street) City: State: Zip: Country: Placement Address if Different: Site Supervisor: Title: CWU Alumnus/a Yes No On-campus supervisors for unpaid internships are required to watch Hiring an Intern video. Phone: Cell Phone: email: Work Hrs Per Week: Academic Hrs Per Week _Number of Weeks: Total Hrs: Paid _Unpaid Wage Per Hr: Other Compensation: (stipend, meals, lodging, mileage) Starting Date: (mm/dd/yyyy) Completion Date (mm/day/year) (If an internship is not completed by the grade due date an “IP” (In Progress) grade can be used. IMPORTANT: Your degree will not be awarded with an IP grade; you will have to re-apply for a future graduation term and pay the re-application fee. PLEASE INITIAL THAT YOU UNDERSTAND ______ EMERGENCY CONTACT INFORMATION Name: Relationship to Intern: Emergency Contact Address: City: State: Zip: Day Phone: Evening Phone: Cell Phone: email: Academic Learning Plan - Faculty Instructor Requirements Course Prefix: Course Number: Number of Credits: Campus Loc Faculty Instructor: Department / Office Phone: Faculty Instructor Email Address: Department Fax Number: Academic Requirements to Be Completed: ( Choose Weekly, Bi-Weekly, monthly, bi-monthly, mid quarter, end of quarter) Term Paper / Project Due: Journal or Log Due: Progress Reports Due: Final Report Due: Assigned Reading: Number of Email Contacts: Other: Is this a continuation of a previous Internship Estimated hours per week outside the internship to meet academic requirements: Faculty advisor or designee expects to contact student during placement as follows: # of job-site visits # of on-campus conferences # of telephone conferences
Appears in 2 contracts
Samples: Learning Agreement, Learning Agreement
OFFICE USE ONLY. Registration Date _________ Course _____________________ Course # ___________ **This form must be typed** STUDENT INFORMATION Name: (First, Middle I., Last) Major: CWU I.D. Number: Work Phone: Evening Phone: Cell Phone: Mailing Address during Internship: _____ _________ City: State: Country*: Zip: CWU email: SKYPE Address______________ Cumulative Credits: (Must have 45 credits to be eligible for 290; 90 credits for 490; grad student for 590 or 690) Current Cumulative GPA: Class Standing: Fresh Soph Jr Sr Post Bac Grad Quarter to Be Registered: 20 Expected Graduating Qtr/Yr: Are you an International Student with a F1 visa? Yes No International students on a F1 visa must obtain the signature of the International Student Advisor Is your internship abroad? Yes No If so- complete the Education Abroad Application. Please take this completed agreement for signature to Study Abroad & Exchange Programs located in room 101 in the International Center if the experience will take place outside of the United States. Have you signed the Student Cooperative Education/Internship Release Form? Yes No Date Have you completed the Sexual Harassment Training? Yes No Attach Certificate of Completion to this form. xxxx://xxx.xxx.xxx/student-employment/required-student-training Date Have you purchased Liability Insurance through the University? (now required) Yes No Date Insurance for non-medical settings and for medical settings. Attach proof of insurance to this form. PLACEMENT INFORMATION Employing Agency: Web URL: Internship Position Title: Business or Agency Type / Industry: Non-Profit For Profit Government Education Employer Mailing Address: (POB or Street) City: State: Zip: Country: Placement Address if Different: Site Supervisor: Title: CWU Alumnus/a Yes No On-campus supervisors for unpaid internships are required to watch Hiring an Intern video. Phone: Cell Phone: email: Work Hrs Per Week: Academic Hrs Per Week _Number of Weeks: Total Hrs: Paid _Unpaid Wage Per Hr: Other Compensation: (stipend, meals, lodging, mileage) Starting Date: (mm/dd/yyyy) Completion Date (mm/day/year) (If an internship is not completed by the grade due date an “IP” (In Progress) grade can be used. IMPORTANT: Your degree will not be awarded with an IP grade; you will have to re-apply for a future graduation term and pay the re-application fee. PLEASE INITIAL THAT YOU UNDERSTAND ______ EMERGENCY CONTACT INFORMATION Name: Relationship to Intern: Emergency Contact Address: City: State: Zip: Day Phone: Evening Phone: Cell Phone: email: Academic Learning Plan - Faculty Instructor Requirements Course Prefix: Course Number: Number of Credits: Campus Loc Faculty Instructor: Department / Office Phone: Faculty Instructor Email Address: Department Fax Number: Academic Requirements to Be Completed: ( Choose Weekly, Bi-Weekly, monthly, bi-monthly, mid quarter, end of quarter) Term Paper / Project Due: Journal or Log Due: Progress Reports Due: Final Report Due: Assigned Reading: Number of Email Contacts: Other: Is this a continuation of a previous Internship Estimated hours per week outside the internship to meet academic requirements: Faculty advisor or designee expects to contact student during placement as follows: # of job-site visits # of on-campus conferences # of telephone conferences
Appears in 1 contract
Samples: Learning Agreement
OFFICE USE ONLY. Registration Date _________ Course _____________________ Course # ___________ **This form must be typed** STUDENT INFORMATION Name: (First, Middle I., Last) Major: CWU I.D. Number: Work Phone: Evening Phone: Cell Phone: Mailing Address during Internship: _____ _________ City: State: Country*: Zip: CWU email: SKYPE Address______________ Cumulative Credits: (Must have 45 credits to be eligible for 290; 90 credits for 490; grad student for 590 or 690) Current Cumulative GPA: Class Standing: Fresh Soph Jr Sr Post Bac Grad Quarter to Be Registered: 20 Expected Graduating Qtr/Yr: Are you an International Student with a F1 visa? Yes No International students on a F1 visa must obtain the signature of the International Student Advisor Is your internship abroad? Yes No If so- complete the Education Abroad Application. Please take this completed agreement for signature to Study Abroad & Exchange Programs located in room 101 in the International Center if the experience will take place outside of the United States. Have you signed the Student Cooperative Education/Internship Release Form? Yes No Date Have you completed the Sexual Harassment Training? Yes No Attach Certificate of Completion to this form. xxxx://xxx.xxx.xxx/student-employment/required-student-training Date Have you purchased Liability Insurance through the University? (now required) Yes No Date Insurance for non-medical settings and for medical settings. settings Attach proof of insurance to this form. PLACEMENT INFORMATION Employing Agency: Web URL: Internship Position Title: Business or Agency Type / Industry: Non-Profit For Profit Government Education Employer Mailing Address: (POB or Street) City: State: Zip: Country: Placement Address if Different: Site Supervisor: Title: CWU Alumnus/a Yes No On-campus supervisors for unpaid internships are required to watch Hiring an Intern video. Phone: Cell Phone: email: Work Hrs Per Week: Academic Hrs Per Week _Number of Weeks: Total Hrs: Paid _Unpaid Wage Per Hr: Other Compensation: (stipend, meals, lodging, mileage) Starting Date: (mm/dd/yyyy) Completion Date (mm/day/year) (If an internship is not completed by the grade due date an “IP” (In Progress) grade can be used. IMPORTANT: Your degree will not be awarded with an IP grade; you will have to re-apply for a future graduation term and pay the re-application fee. PLEASE INITIAL THAT YOU UNDERSTAND ______ EMERGENCY CONTACT INFORMATION Name: Relationship to Intern: Emergency Contact Address: City: State: Zip: Day Phone: Evening Phone: Cell Phone: email: Academic Learning Plan - Faculty Instructor Requirements Course Prefix: Course Number: Number of Credits: Campus Loc Faculty Instructor: Department / Office Phone: Faculty Instructor Email Address: Department Fax Number: Academic Requirements to Be Completed: ( Choose Weekly, Bi-Weekly, monthly, bi-monthly, mid quarter, end of quarter) Term Paper / Project Due: Journal or Log Due: Progress Reports Due: Final Report Due: Assigned Reading: Number of Email Contacts: Other: Is this a continuation of a previous Internship Estimated hours per week outside the internship to meet academic requirements: Faculty advisor or designee expects to contact student during placement as follows: # of job-site visits # of on-campus conferences # of telephone conferences
Appears in 1 contract
Samples: Learning Agreement
